Chapter 26 review questions

When a patient is diagnosed with acute bacterial pharyngitis, which prescribed medication would the nurse question? A. Nystatin B. Ibuprofen C. Penicillin G D. Acetaminophen

A. Nystatin Rationale; Nystatin is an antifungal medication that is used to treat fungal pharyngitis, most typically caused by Candida. Penicillin is the preferred treatment for bacterial pharyngitis. Ibuprofen and acetaminophen are recommended for pain and fever relief

Which assessment is most important to obtain for a patient with a radical neck dissection who is refusing any enteral feeding? A. Weight B. Pulse rate C. BP D. Respiratory rate

A. Weight

Which diagnosis will the nurse expect for a patient who recently brought home a cat and presents with a persistent runny nose, sneezing, watery eyes, a recent onset of headache and nasal congestion? A. Influenza B. Common cold C. Allergic rhinitis D. Nasal septal deviation

C. Allergic rhinitis

Which topics will the nurse include in discharge teaching for a patient who has had a complete laryngectomy? Select all that apply A. How to obtain a medic alert bracelet B. Care of the stoma or laryngectomy tube C. Ways to hide the stoma with a scarf or shirt D. Use of a smartphone with a text- to speech app E: Ways to decrease aspiration risk when swallowing

A. How to obtain a medic alert bracelet B. Care of the stoma or laryngectomy tube C. Ways to hide the stoma with a scarf or shirt D. Use of a smartphone with a text- to speech app

Which clinical manifestations will the nurse expect to find when assessing a patient with oral mucositis? Select all that apply, A. Pain B. Irritation C. Ulceration D. Dental caries E. Nasal congestion

A. Pain B. Irritation C. Ulceration

Which statement made by the student nurse demonstrates understanding regarding the care of the patient's tracheostomy tube? A. "The extra tracheostomy tube will be kept at the nurses' station." B. "The obturator should be removed after tube insertion." C. "The outer cannula will be inserted in the obturator." D. "The tracheostomy cuff is inflated when the patient needs to speak."

B. "The obturator should be removed after tube insertion."

Which clinical manifestation is an early sign of laryngeal cancer? A. Discolored purulent nasal drainage B. Hoarseness for more than two weeks C. Tenderness at the ethmoidal sinuses D. Nasal cavity filled with mucous fluid

B. Hoarseness for more than two weeks

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

a. Clear nasal drainage rationale: Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being stuck up my nose and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

d. Have the patient occlude the left nare and blow the nose. rationale: Because the highest priority action is to remove the foreign object from the nare, the nurses first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

Which instructions will the nurse provide to the patient with rhinitis about managing side effects of prescribed chlorpheniramine? Select all that apply. A. "Avoid driving for a few days." B. "Drink carrot juice once daily." C. "Always carry liquids with you." D. "Monitor your blood pressure daily." E. "Add fiber- rich food and fruits to your diet.

A. "Avoid driving for a few days." C. "Always carry liquids with you." E. "Add fiber- rich food and fruits to your diet.

After the nurse has provided teaching to a community group about how to prevent head and neck cancer, which statement by a group member indicates that more teaching is needed? A. "Chewing tobacco is better than smoking." B. "If you smoke, stop. If you don't, don't start." C. "Alcohol in moderation, but no alcohol is best." D. "Brush three times daily and floss at least once."

A. "Chewing tobacco is better than smoking."

Which instructions will the nurse include in teaching a patient and family first aid measures for epistaxis? select all that apply A. Tilt the patient's head backwards B. Apply ice compresses to the nose C. Tilt the head forward while lying down. D. Pinch the entire soft lower portion of the nose E. Partially insert a small gauze pad into the bleeding nostril

A. Apply ice compresses to the nose D. Pinch the entire soft lower portion of the nose E. Partially insert a small gauze pad into the bleeding nostril

Which drug is used as a targeted therapy for head and neck cancer? A. Cetuximab B. Olopatadine C. Mometasone D. Ipratropium bromide

A. Cetuximab Rationale: is an anticancer agent used as a targeted therapy in the head and neck cancer after standard chemotherapy. Olopatadine is effective in the treatment of rhinitis. Mometasone is a corticosteroid used in the treatment of sinusitis and allergic rhinitis. Ipratropium bromide is an anticholinergic used to treat rhinitis

Which surgery is associated with the partial removal of one vocal cord A. Cordectomy B. Partial laryngectomy C. Vocal- cord stripping D. Radical neck dissection

A. Cordectomy

A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) A. Cover the nose when coughing. B. Obtain an influenza vaccination. C. Stay at home when symptomatic. D. Drink noncaffeinated fluids daily. E. Obtain antibiotic therapy promptly.

A. Cover the nose when coughing. B. Obtain an influenza vaccination. C. Stay at home when symptomatic. rationale: Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

When the nurse does patient teaching about how to decrease risk for head and neck cancer, which instructions will be included? Select all that apply. A. Limit your alcohol intake B. Brush your teeth at least daily C. Avoid spicy foods, such as chilies D. Stop use of chewing tobacco and cigarettes E. Use condoms for oral sex and sexual intercourse

A. Limit your alcohol intake B. Brush your teeth at least daily D. Stop use of chewing tobacco and cigarettes E. Use condoms for oral sex and sexual intercourse

Which changes are expected in a patient after undergoing a total laryngectomy? Select all that apply. A. Loss of taste B. Loss of smell C. Loss of vision D. Loss of speech E. Loss of motor function

A. Loss of taste B. Loss of smell D. Loss of speech

The nurse will include which teaching for a patient with sinusitis? select all that apply. A. Take plenty of rest B. Drink plenty of water. C. Take a cool water bath twice a day D. Sleep with the head in a lower position E. Perform large- volume nasal saline washes once or twice a day

A. Take plenty of rest B. Drink plenty of water. E. Perform large- volume nasal saline washes once or twice a day

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? A. Test the drainage for the presence of glucose. B. Suction the nose to maintain airway clearance. C. Document the findings and continue monitoring. D. Apply a drip pad and reassure the patient this is normal.

A. Test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

Which patient assessment data indicate increased risk for head and neck cancer? Select all that apply A. Tobacco use B. Female gender C. Poor oral hygiene D. Age 40 to 50 years E. Excessive alcohol consumption

A. Tobacco use C. Poor oral hygiene E. Excessive alcohol consumption

Which action will the nurse include when changing a tracheostomy dressing? A. Use unlined gauze B. Cut the gauze before using it C. Change the dressing once every two days D. Use the sterile gloves to remove the used dressing

A. Use an unlined gauze

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? A. "Are you allergic to chicken?" B. "Could you be pregnant now?" C. "Did you ever have influenza?" D. "Have you ever had hepatitis B?"

B. "Could you be pregnant now?" rationale: The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? A. Patient comfort B. Airway patency C. Incisional drainage D. Blood pressure and heart rate

B. Airway patency rationale: Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

Which nursing action indicates good understanding of the postoperative care of the patient who has had a complete laryngectomy? A. Keeping the neck extended for the first few postoperative days B. Helping the patient use a smartphone text- to- speech application C. Repositioning the nasogastric tube to relieve abdominal distension D. Avoiding tracheal suctioning during the early postoperative period

B. Helping the patient use a smartphone text- to- speech application

When a patient with a newly inserted tracheostomy suddenly coughs and expels the tracheostomy tube, which action will the nurse take first? A. Suction the tracheostomy opening B. Hold the stoma open with a sterile hemostat. C. Use a bag valve mask to ventilate the patient D. Attempt to reinsert a new sterile tracheostomy tube.

B. Hold the stoma open with a sterile hemostat.

The nurse will educate a patient to include which interventions for the management of rhinitis due to an allergy to mold? Select all that apply. A. Remove pets from the house B. Keep closets and basements well lit. C. Drape the windows well to limit light. D. Keep plants inside the house in large numbers E. Ensure good ventilation to allow ample airflow in the house

B. Keep closets and basements well lit. E. Ensure good ventilation to allow ample airflow in the house

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? A. Suction the tracheostomy opening. B. Maintain the airway with a sterile hemostat. C. Use an Ambu bag and mask to ventilate the patient. D. Insert the tracheostomy tube obturator into the stoma.

B. Maintain the airway with a sterile hemostat. Rationale: As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

Which action by the student nurse indicates understanding regarding routine tracheostomy care? A. Cleaning around the stoma once every 24 hours B. Maintaining tracheostomy cuff pressure of 20 mm Hg C. Using a one- person technique to change tracheostomy tapes D. Cutting a gauze square to make a new tracheostomy dressing

B. Maintaining tracheostomy cuff pressure of 20 mm Hg

Which patient with a tracheostomy requires a change in the plan of care? A. Patient A: Tracheostomy tube with cuff and pilot balloon- maintain a cuff pressure of < or equal to 20 mm Hg B. Patient B: Fenestrated tracheostomy tube- insert decannulation plug in tracheostomy tube before deflating the cuff C. Patient C: Talking tracheostomy tube- Disconnect flow when patient does not want to speak D. Patient D: Tracheostomy tube with foam- filled cuff - before insertion, withdraw all air from the cuff using a 20 - mL syringe and cap pilot balloon.

B. Patient B: Fenestrated tracheostomy tube- insert decannulation plug in tracheostomy tube before deflating the cuff Rationale: The nurse should never insert a decannulation plug into the tracheostomy tube until the cuff is deflated because it will obstruct airflow and can cause respiratory arrest

Which interprofessional action will the clinic nurse plan to take after assessing a patient with a scratchy throat, severe pain, and enlargement of the anterior cervical lymph node? A. Schedule a chest x-ray B. Perform a rapid antigen- detection test C. Prepare for needle aspiration of the lymph node D. Transfer the patient to the emergency department

B. Perform a rapid antigen- detection test

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? A. Level of consciousness B. Quality of breath sounds C. Presence of the gag reflex D. Tracheostomy cuff pressure

B. Quality of breath sounds Rationale: Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.

Which task can the RN delegate to properly trained unlicensed assistive personnel (UAP) when caring for a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure

B. Suctioning the patient's oropharynx

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? A. Assessing the need for suctioning B. Suctioning the patient's oropharynx C. Assessing the patient's swallowing ability D. Maintaining appropriate cuff inflation pressure

B. Suctioning the patient's oropharynx Rationale: Providing the person has been trained in correct technique, the UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse. An RN should perform a swallowing assessment and maintain cuff inflation pressure.

Which instructions will the nurse include in teaching a patient with allergic rhinitis about the use of corticosteroid nasal spray? Select all that apply A. Use the spray as needed B. Use the spray twice daily, as ordered. C. Discontinue use if nasal infection occurs D. Start two weeks before pollen season begins E. Clear nasal passages before using the spray.

B. Use the spray twice daily, as ordered. C. Discontinue use if nasal infection occurs E. Clear nasal passages before using the spray.

Which clinical finding is associated with oral cancer? A. Throat pain B. White patches in the mouth C. Recurrent need to clear the throat D. Voice hoarseness for more than two week s

B. White patches in the mouth

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patients oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

B. attempt to reinsert the tracheostomy tube with the obturator in place. rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway. Assessing the patients oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? A. Bilateral erythema of especially large tonsils B. Temperature 102.2° F, diaphoresis, and chills C. Contraction of neck muscles during inspiration D. β-Hemolytic streptococcus in the throat culture

C. Contraction of neck muscles during inspiration Rationale: Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? A. Nasal packing B. Epistaxis balloon C. Gastrostomy tube D. Peripheral skin care

C. Gastrostomy tube Rationale: Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral nutrition via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.

For staging of head and neck cancer, which letter indicates whether cancer has spread to another part of the body? A. T B. N C. M. D. D

C. M

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? A. Electrolyte levels and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

C. Respiratory rate and oxygen saturation Rationale: The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? (Select all that apply.) A. Tilt patient's head backwards. B. Apply ice compresses to the nose. C. Tilt head forward while sitting upright. D. Pinch the entire soft lower portion of the nose. E. Lying down until 15 minutes after the bleeding ceases

C. Tilt head forward while sitting upright. D. Pinch the entire soft lower portion of the nose. rationale: Use simple first aid measures to control nosebleeds. These include: (1) placing the patient in a sitting position, leaning slightly forward with head tilted forward and (2) applying direct pressure by squeezing the entire soft lower portion of the nose (nostrils) together for 5 to 15 minutes. Tilting the head back does not stop the bleeding but allows the blood to enter the nasopharynx, which could result in aspiration or nausea or vomiting from swallowing blood. Lying down also will not decrease the bleeding.

Which communication technique for a patient after laryngectomy involves creation of a fistula between the esophagus and trachea in a patient? A. Electrolarynx B. Esophageal speech C. Transesophageal puncture D. Keyboard- based communication program

C. Transesophageal puncture

Which instruction will the nurse include in discharge teaching for a patient who has had tracheostomy? A. wash the area around the stoma at least 4 times a day B. Use a plastic collar when swimming to prevent aspiration of water C. Wear a medic alert bracelet or other form of emergency identification D. Avoid covering the stoma when coughing so that secretions can be expectorated

C. Wear a medic alert bracelet or other form of emergency identification

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? A. "My liver function will be checked with blood tests every 2 to 3 months." B. "The medication will decrease the congestion within 3 to 5 minutes after use." C. "I may develop a serious infection because the medication reduces my immunity." D. "I will use the medication every day of the season whether I have symptoms or not."

D. "I will use the medication every day of the season whether I have symptoms or not." rationale: Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? A. "I should avoid using ibuprofen for pain and discomfort." B. "It is important for me to take my blood pressure medication every day." C. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." D. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

D. "If I get a nosebleed, I will lie down flat and raise my feet above my heart." Rationale: A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure is to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin and nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed

The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? A. Family history of lung cancer B. Recent inhalation of noxious fumes C. Frequent straining of the vocal cords D. Chronic use of alcohol and tobacco products

D. Chronic use of alcohol and tobacco products rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol use is another major risk factor. Other risk factors include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene.

When caring for a patient who reports many years of work applying asbestos roofing, the nurse will screen for which condition? A. Rhinitis B. Nasal polyps C. Bacterial pharyngitis D. Head and neck cancer

D. Head and neck cancer

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? A. Age older than 80 years B. History of upper respiratory infections C. Chronic obstructive pulmonary disease (COPD) D. History of a severe allergic reaction to the vaccine

D. History of a severe allergic reaction to the vaccine Rationale: Contraindications to vaccination include a history of severe allergic reactions to previous flu vaccine. Patients with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP, as alternatives for vaccinating patients with egg allergies are now available. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? A. Apply an external splint to the nose. B. Insert plastic nasal implant surgically. C. Humidify the air for mouth breathing. D. Maintain surgical packing in the nose.

D. Maintain surgical packing in the nose. Rationale: A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? A. Coughing B. Fever, chills C. Dust allergy D. Maxillary pain

D. Maxillary pain rationale: The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Suction the tracheostomy. B. Check stoma site for skin breakdown. C. Complete tracheostomy care using sterile technique. D. Provide oral care with a toothbrush and tonsil suction tube.

D. Provide oral care with a toothbrush and tonsil suction tube. rationale: Oral care (for a stable patient with a tracheostomy) can be delegated to UAP. A registered nurse would be responsible for assessments (e.g., checking the stoma for skin breakdown) and tracheostomy suctioning and care.

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? A. Electromyography B. Intraoral electrolarynx C. Neck type electrolarynx D. Transesophageal puncture

D. Transesophageal puncture Rationale: The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A 23-year-old who is complaining of a sore throat and has a muffled voice b. A 34-year-old who has a scratchy throat and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

a. A 23-year-old who is complaining of a sore throat and has a muffled voice rationale: The patients clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and cephalosporins

a. A 76-year-old nursing home resident b. A 36-year-old female patient who is pregnant d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis rationale: Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection.

1. The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a. Decongestants can be used to relieve swelling. b. Blowing the nose should be avoided to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

a. Decongestants can be used to relieve swelling. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position. rationale: The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask? a. How much alcohol do you drink in an average week? b. Do you have a family history of head or neck cancer? c. Have you had frequent streptococcal throat infections? d. Do you use antihistamines for upper airway congestion?

a. How much alcohol do you drink in an average week? rationale: Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patients symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patients symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. I must keep the stoma covered with an occlusive dressing at all times. b. I can participate in most of my prior fitness activities except swimming. c. I should wear a Medic-Alert bracelet that identifies me as a neck breather. d. I need to be sure that I have smoke and carbon monoxide detectors installed.

a. I must keep the stoma covered with an occlusive dressing at all times. rationale: The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patients airway. The other patient comments are all accurate and indicate that the teaching has been effective.

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. I will need to buy a water bottle to carry with me. b. I should not use any lotions on my neck and throat. c. Until the radiation is complete, I may have diarrhea. d. Alcohol-based mouthwashes will help clean oral ulcers.

a. I will need to buy a water bottle to carry with me. rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with nonalcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

Which action should the nurse take first when a patient develops a nosebleed? a. Pinch the lower portion of the nose for 10 minutes. b. Pack the affected nare tightly with an epistaxis balloon. c. Obtain silver nitrate that will be needed for cauterization. d. Apply ice compresses over the patients nose and cheeks.

a. Pinch the lower portion of the nose for 10 minutes. rationale: The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patients temperature is 100.1 F (37.8 C). d. The patient complains of level 8 (0 to 10 scale) pain.

a. The oxygen saturation is 89%. rationale: Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. d. The wound drain in the neck incision contains 200 mL of bloody drainage c. The nasogastric (NG) tube is disconnected from suction and clamped off.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

a. Use a manometer to ensure cuff pressure is at an appropriate level. rationale: Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patients airway is occluded. A health care providers order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? a. Fever of 100.4 F (38 C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

b. Diffuse crackles in the lungs rationale: The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the- counter (OTC) pain relievers and increased fluid intake.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patients risk for aspiration. b. Suction the tracheostomy when needed. c. Teach the patient about self-care of the tracheostomy. d. Determine the need for replacement of the tracheostomy tube.

b. Suction the tracheostomy when needed. rationale: Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6 F (38.7 C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

b. Use a swab to obtain a sample for a rapid strep antigen test. rationale: The patients clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patients assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

c. Assess the ability to swallow before using the fenestrated tube. rationale: Because the cuff is deflated when using a fenestrated tube, the patients risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patients airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patients vocal cords when using a fenestrated tube.

The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. I can take acetaminophen (Tylenol) to treat my discomfort. b. I will drink lots of juices and other fluids to stay well hydrated. c. I can use my nasal decongestant spray until the congestion is all gone. d. I will watch for changes in nasal secretions or the sputum that I cough up.

c. I can use my nasal decongestant spray until the congestion is all gone. rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning

c. Put on sterile gloves and use a sterile catheter to suction. rationale: This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a. The patient lets the spouse provide tracheostomy care. b. The patient allows the nurse to suction the tracheostomy. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request No Visitors.

c. The patient asks how to clean the tracheostomy stoma and tube. rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a. I can take 800 mg ibuprofen for pain control. b. I will safely remove and reapply nasal packing daily. c. My nose will look normal after 24 hours when the swelling goes away. d. I will keep my head elevated for 48 hours to minimize swelling and pain.

d. I will keep my head elevated for 48 hours to minimize swelling and pain. Rationale: Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

d. Identification and avoidance of environmental triggers are the best way to avoid symptoms. rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor for bleeding. b. Maintain adequate IV fluid intake. c. Suction tracheostomy every eight hours. d. Keep the patient in semi-Fowlers position.

d. Keep the patient in semi-Fowlers position. rationale: The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowlers position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

The nurse is caring for a patient who has acute pharyngitis caused byCandida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Avoid giving patient warm liquids to drink. b. Assess patient for allergies to penicillin antibiotics. c. Teach the patient about the need to sleep in a warm, dry environment. d. Teach patient to swish and swallow prescribed oral nystatin (Mycostatin)

d. Teach patient to swish and swallow prescribed oral nystatin (Mycostatin) rationale: Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the swish and swallow technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, Will I be able to talk normally after surgery? What is the best response by the nurse? a. You will breathe through a permanent opening in your neck, but you will not be able to communicate orally. b. You wont be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed. c. You wont be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally. d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.

d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration. rationale: Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.